Marginal Musings from a New England Author

Decisions, Decisions

These days the subject of medical error has become a hot topic. Morbidity and mortality secondary to medical error is staggering. Groopman has delineated some of the foibles in medical decision making. Gawande has proposed a standard check list to curb the number of surgical errors. Leading experts opine that widespread implementation of the electronic medical record might serve to drastically reduce the number of errors made by practicing clinicians.

Now New York Times science columnist John Tierney delves into the subject of decision making by examining not how decisions are made, but rather the state of mind of the decision maker. Citing recent extensive psychological research, Tierney proposes that the attentiveness and care that we muster when making a decision seems to be directly dependent upon the supply of glucose to our brains.

In the Times article (which is adapted from a book Tierney authored with Roy F. Baumeister, Willpower: Rediscovering the Greatest Human Strength),Tierney expounds on the concept of decision fatigue, the idea that the more decisions we are forced to make during the course of the day, the more likely we are to opt for the path of least resistance. Either we act impulsively or refuse to commit to making a choice.

Obviously, in medical practice either tack has the very real potential of resulting in suboptimal care for the patient.

“‘Good decision making is not a trait of the person, in the sense that it’s always there,’ Baumeister says. ‘It’s a state that fluctuates.’ His studies show that people with the best self-control are the ones who structure their lives so as to conserve willpower.”

“The restored willpower improved people’s self-control as well as the quality of their decisions: they resisted irrational bias when making choices…they were more likely to choose the better long-term strategy instead of going for a quick payoff.”

Nearly all practicing clinicians do not enjoy the luxury of structured 4-hour workdays. We are thrown into the daily fray, forced to evaluate those patients that find their way to us in whatever area of clinical medicine we work.

So what can we do to avoid decision fatigue?

As it turns out, “glucose is a vital part of willpower….Your brain does not stop working when glucose is low. It stops doing some things and starts doing others. It responds more strongly to immediate rewards and pays less attention to long-term prospects.”

If these data are to be believed, in order to keep our minds sharp one simple solution might be a mid-afternoon snack consisting of a load of glucose: perhaps a sugary soft drink coupled with a cookie.